autologus blood donations

[ccmd]

Why can't we stop collecting/wasting autologus bood?

[Cliff]

You can, you will be very unpopular with your surgeons though.

I suspect that autologous donation is more of a "right" than other types of donation. It would be fairly hard to eliminate them altogether.

Some things you can try are too educate the ordering physicians.

In our institution we discard roughly half of what we collect.

We recently stopped accepting auto units from suppliers, we hope this will save us a lot of money. We collect our own autos and patients will need to come to our facility from now on. Of course we will make exceptions.

[conwaysbb]

Unfortunately for the blood banks in New Jersey wh have the blood Safety Act of 1992 that requires any physician to inform their patients of the alternatives to receiving volunteer blood to include directed and autologous.

We are also required to accept any autiologous or directed blood from any outside blood center. Additionally, there is a New Jersey State Department of Health requirement that we can not cross over auto units, we waste approximately 50% of our units.

However, as we offer autologous and directed collections at our facility , it is a benefit in attracting patients to our facility and we can always corssover our directed

[Laura]

I agree that the issue of ordering autologous units has a lot to do with physician and patient education. I look at autologous donations as a patient's ability to have some control over their treatment.

Nationally, half the autologous that is drawn is wasted. I will be curiouos to see how long insurance companies will continue to pay for these units.

I do want to comment on the issue of crossing over directed units. We have not crossed over directed units in my area for years. I'm not sure that you can consider these donors as true volunteer donors. In the years that I managed the special collections department in our local blood center, I saw directed donors who were either pressured to donate, or who wanted to donate for a loved one so badly that they would not always be up front with their information.

Statistically, directed donors have a higher rate of positive infectious disease markers than the pool of volunteer donors.

I know that if someone I loved needed blood, I would not want it to come from a directed donor. And if you are in an area where financial "credit" is given for directed units, I really wouldn't consider using them for anyone else.

[Cliff]

I too agree that directed donors may not be the most honest and altruistic; however, if we agree to take them as donors, then I feel we need to feel comfortable crossing them over. I can't rationalize it if I say they are acceptable for a person they select, but we won't allow it to go to someone else.

The autologous situation will likely be here for a long time, I don't think the donors will truly understand that autologous donation is not safer than homologous donation.

[Jane]

We are a hospital based transfusion service that only collects autologous units. It is very difficult for us because our staff has been cut (it is based on billable tests and spending an hour with a donor is only 1 billable test). I am working now to do away with this program and there are many journal articles to support this position. The patients could still donate at the American Red Cross about 1/2 hour away. There are many articles that support the position that many of the donors would not need a transfusion if they hadn't donated their own blood.

[David Saikin]

It seems you all are having an opposite spectrum of events than I am . . . My Docs don't order any autologous, in fact, we draw for a few other area hospitals. So far this year I have drawn 2 units . . . last year 10. We would prefer having autologous, as this would allow our very small blood supply to go farther. I guess it's all a matter of perspective.

[Cliff]

David, I agree that it may help supplement the general inventory. I guess I want it both ways. Collecting autologous costs us a lot of money, we collect several thousand a year. We will start collecting significantly more, we have recently restricted auto collections to our facility only, we do not allow our local suppliers to collect for us, except in rare circumstances. We discard about 1/2 and obviously can't get reimbursed for those.

So perhaps it's not the collection of auto units that frustrates us, but the over ordering.

[Alan Hoffstadter]

Oddly, the reponse to our problem of draw-it-and-discard-it came from some of the physicians themselves. "Traditionally," it's been the Urologists (Radical Prostatectomies) and the Orthopedic Surgeons (hip and knee replacements). The ortho team bought an OrthoPAT device (Zimmer) and simply stopped sending donors.

Of course the intra-and-post-operative salvage device is, in and of itself, yet another kettle of fish...........

[mthomas]

I agree that it is hard to disuade surgeons from requesting PAD, but the real answer is to educate them to use Intraoperative Cell Salvage. I have always called this "Green Blood" as it is esentially environmentally friendly. It has always seemed madness to me to suck up blood from the wound and then go to great lengths to dispose of theis "Hazardous Clinical Waste" while, at the same time, grabbing some poor sucker off the streets and bleeding him/her to provide an allogeneic unit for transfusion. Why not simply collect the shed blood, wash it and return it to the patient?

Useful references, although a little old, are:

Thomas MJG, Gillon J, Desmond MJ. Preoperative autologous transfusion. Transfusion. 1996;36(7):633-639.

Desmond MJ, Thomas MJG, Gillon J, Fox MA. Perioperative red cell salvage. Transfusion. 1996;36(7):644-651.

Thomas MJG, Desmond MJ, Gillon J. Preoperative autologous donation: what was the impact of the 1995 consensus statement? Transfusion Medicine. 1999;9(3):241-57.

Desmond M, Gillon J, Thomas MJG. Perioperative red cell salvage: a case for implementing the 1995 consensus statement. Transfusion Medicine. 1999;9(3):265-8.

Thomas MJG. Infected and malignant fields are an absolute contraindication to intraoperative cell salvage: fact or fiction? Transfusion Medicine. 1999;9(3):269-78.

Phillips P, Gray A, Thomas MJG. An audit of autologous blood transfusion in the UK. Transfusion Medicine. 1999;9(3):284.

Thomas MJG. Uncross-matched blood is unnecessary. Hospital Medicine. 2005;66(2):96-8

[sharon]

I have been working with my orthopedic physicians who perform total joints and have been very successful in drastically reducing autologous donations and transfusions. There is a good article in the Journal of Bone and Joint Surgery July 2004 by Tim Hannon with an alogrithm that I modified a little but works. We collect all of their auto units and I showed the physicians their own pt data and also provided them with info about lowering the transfusion trigger. I also took a big step and changed our criteria for auto donation. Auto donors must complete their donations with in 21 days of surgery and I increased the hgb requirements. So far no complaints. My next group to work with are the spine surgeons.

[bbkdiane]

Each month I tally the wastage for the Blood Bank. The Autologous wastage is listed by physician with the number of units wasted and the price tag of the wastage. This report is sent by e-mail to the head of the Orthopaedic Center (we have a huge one) and to the Administration. I can tell you right now, this is an excellent way to start dialogue because the surgeons have no clue how much is wasted unless you take the time to spell it out for them. Our surgeons amended their scripts for the blood center to say: "Please perform a hematocrit on my patient. If the hematocrit is above 41%, do NOT draw any Autologous units." Hip and Knee replacement pre-donations are at zero to 1 unit per patient. Like others have expressed, there is always pressure legally and ethically to promote Autologous pre-donation for large elective cases. We do employ intra operative and post operative blood salvage. Most of the patients are elderly so if they have to get a unit or two of bank blood post surgery (usually a day or two later in rehab) they would not live long enough to get ill from any of the viral risks that could be in the blood. Our Auto wastage hovers around 26 to 33%; if you consider the national average of approx. 50%, I think we're doing something right. There is always room for improvement, but I believe that 0% wastage is probably not a realistic achievement.

[Mark]

Unfortunately, it is the surgeon and anesthesiologist that are at fault in wasting autologous predonations. This very expensive and completely not necessary. Patients often recieve anywhere from 500 cc's to 1000 cc's of crystaloid solution during a routine procedure and then become a little hemodiluted. It would not be that much trouble to hang the patient's own blood. The added citrate could easily be reversed with a touch of calcium chloride. It's laziness and a lack of concern for the expense of the bloodbank and effort by the patient to donate this unit. Education is definitely needed for the surgeons and anesthesiologists by the hospital bloodbank manager or physician director to get the message across. As a Perfusionist, I perform acute normovolemic hemodilution in the OR for many heart patients and believe me, I see to it that the patient gets every drop of pre-donated autologous back. The surgeons I work with are very happy for my efforts. Another means of getting the mesage across mught be for the off-site bloodbank director to issue a written statement to the ordering surgeons addressing the problem and making them aware of the costs both monetarily and in patient time and effort to pre-donate. Maybe if the ordering surgeons themselves would give a unit or two of blood and then have it thrown in garbage, then maybe some changes would come about.

Mark

[KC Roberts MS CP CCA]

The College of American Pathologists did a survey and published it QProbe 1996 that studied 600 major medical centers discussing blood utilization. Even though the survey is now eight years old, many of the conclusions are still valid. I highly recommend you review this document. One of the many interesting points made was that many patients who participated in PABD actually increased the probability of receiving allogeneic bank blood.

The solution to this problem is the initiation of a Perioperative Blood Management Program that creates an appropriate balance in its system for both allogeneic and autologous products. Once the program is developed, the surgeons and anesthesiologists should be educated as to the most appropriate Tx options. My program has reduced an 80% Discard Rate to less than 25%. It Works!

K.C. Roberts, MS, CP, CCA